Supporting Black Maternal Health Clinicians as an Avenue to Improving Maternal Outcomes 

Maternal mortality in the United States is more than three times the rate in most other high-income countries–and it is worsening. The rate more than doubled between 1999 and 2019. US maternal deaths are disproportionately higher among Black women, who are at least 3.5 times more likely to die from pregnancy-related causes as their White counterparts and twice as likely to suffer serious pregnancy complications  such as hemorrhage, preeclampsia, and heart problems.  

Identifying ways to increase the participation of Black clinicians in the maternal and perinatal health field is an essential step toward improving Black birth outcomes. Multiple studies support this approach, showing that racial concordance between patients and practitioners improves patient health outcomes, from infant mortality to cardiovascular mortality. Patients who are the same race, ethnicity, and spoken language as their providers report better outcomes and are more likely to report receiving quality care and better communication. 

Black Maternal Health Clinicians Face Several Challenges 

Despite this growing body of evidence, there is a shortage of maternal health providers of color, including midwives, labor and delivery (L&D) nurses, and obstetrician/gynecologists (OB/GYNs). The proportion of Black OB/GYN residents actually declined between 2014 and 2019, and a 2021 national report found that only 7% of certified nurse midwives/certified midwives (CNMs/CMs) identified as Black or African American. In 2020, just 6.7% of registered nurses in the US were Black, although Black Americans made up 12.4% of the population. 

In 2022, the Urban Institute partnered with the California Health Care Foundation to chart a path toward increasing the number of Black maternal health care clinicians both within the state and across the country. Focusing on California, Urban researchers conducted qualitative interviews and a review of the relevant literature to examine opportunities for, and barriers to, increasing the number of Black licensed clinicians—specifically OB/GYNs, L&D nurses, and midwives—understanding that California data would shed light on a larger national problem.  

Our analysis found systematic evidence that: 

• Black clinicians face repeated career hurdles that begin during training, including financial challenges, lack of mentoring, and workplace racism; and  
• Black clinicians face education and workplace challenges that are specific to the fields of obstetrics, midwifery, and L&D nursing. 

Policy Principles for Supporting Black Maternal Health Clinicians 

Specific solutions will (and should) vary across states, but here are three overarching policy principles for increasing the numbers of Black birthing clinicians and supporting their success.  

1. Recruit: create and support career pathways for Black maternal health clinicians and ensure that they lead into healthy supportive, and antiracist environments that produce and retain healthy, diverse providers. 

• Stop “pushout” practices that exclude or discourage potential health professions students from educational opportunities, beginning in the K-12 period and continuing through residency, apprenticeships, and clinical careers. For example, Erica Taylor, who is now the first Black female orthopedic surgeon at Duke Health, was once advised “that orthopedics was too hard and most people like me go into family medicine or maybe OB-GYN.” Many of the professionals we interviewed for our report said they’d been discouraged at least once from pursuing a career in health care. One interviewee described “a large naysaying circle of people who do not believe in the power and capacity of Black people, and those naysayers hold much of the influence in deciding who enters the field.” 
• Build more support for mentorship, which is vitally important to the success of Black care providers. Concordance along intersectional identities and career interests is ideal, but not always practically possible. In any event, mentoring should start when aspiring professionals are young and continue through clinical practice. 

2. Support: reduce the vast financial barriers for aspiring Black maternal health care providers that cause many to forego this work. In our research, interviewees frequently described debt as a barrier to both entering and staying in the nursing profession. 

• Provide federal, state, or private scholarships for those who are unable to secure loans and/or cannot afford them, with loan repayment programs for others. Programs like the federal government’s Nurse Corps Loan Repayment Program could provide loan repayment opportunities that address the disproportionate debt Black students take on to finance their educations. 
• Create and sustain federally or state financed paid midwifery apprenticeship opportunities in a variety of settings (analogous to what is done for medical residents). Midwives often lose revenue and relationships with patients during apprenticeships.  
• Provide funding for students’ basic needs in addition to tuition, housing, and books, including funding for emergencies, such as California’s Nursing Education Investment Grants Program, which is designed to support community college nursing students by providing small grants to those who experience financial hardship. 

3. Retain: change system structures and finances to support and retain Black maternal care providers. 

• Incentivize health care systems to expand and improve reimbursement for the provider types that have helped reduce negative maternal and infant health outcomes, including doulas and midwives. States have a key role in defining scope of practice and allowing these providers to deliver services within their training and ability without physician supervision.   
• Reimburse maternal care providers in a manner that allows ongoing engagement with birthing people, prenatally, during birth and during the postpartum period.  
• Require Medicaid and encourage other insurers to reimburse for maternal health care in a variety of settings, including the home, birth centers, and hospitals, while including quality safeguards and also continually monitoring for equitable access to and outcomes from these services. In Massachusetts, a bill currently under consideration would integrate midwifery care into the state’s maternal health system to improve access to out-of-hospital birthing options and reduce barriers to the creation of free-standing birth centers.

What State Agencies Can Do 

There are several actions steps that Medicaid and other state agencies can take to improve workforce diversity in maternal health.   

1. Data Collection for Accountability: To get a better grasp of current shortages, states should gather, disaggregate, and evaluate baseline provider demographics from provider databases managed by licensing boards, payors, and provider census stewards. Leadership can leverage this data to: 

• Work with constituents, including prospective students, to understand the steps and partnerships needed to improve diversity in health professions along all intersectional identities (e.g., race, ethnicity, gender identity).  
• Assess progress on workforce diversity. In Minnesota, for example, there is legislation that requires a biennial report on the effectiveness of state maternal and infant health policies and programs addressing health disparities, including promoting racial diversity in the workforce.  
• Partner with contracted insurers to develop accountability for a plan to increase engagement and retention to achieve a representative workforce.

2. Medicaid Policies: The underrepresentation of Black clinicians is payer agnostic. However, Medicaid covers approximately 42% of US births and offers a platform to expand existing programs, policies, and practices that support workforce diversification — and to develop and evaluate new ones. For example:  

• State Medicaid agencies can use both RFP bidding language and contracting ability to require Medicaid insurers to demonstrate provider demographics that represent the population served. Metrics should include the numbers of first-time contracting providers, ongoing retention of providers, and the number of, and reasons for, providers leaving insurance panels.  
• Medicaid agencies, along with states and the federal government, can commit to enforcing anti-discrimination laws and policies that are already in place; Maryland’s employment rules are one example.  

Together, these strategies could give Black maternal care providers the support they need to thrive throughout their professional journeys and to do the critical work of improving maternal outcomes and advancing health equity. They will work best if mentors, schools, residencies, hospitals, and clinics engage and partner with Black professionals in all stages of training and practice to understand and enact changes in policy and practice based on what is working and where there can be improvement.